To submit a prior authorization online, please click the button below to use the web form.
PDF forms are available below to submit a prior authorization through fax.
| Title | Categories | Update Date | Download |
|---|---|---|---|
|
Compounding Coverage Authorization Request Form 212 downloads |
BCBSAL | December 3, 2020 | Download |
|
FDA Medwatch Form 136 downloads |
BCBSAL, BCBSFL, HiLab, sscripts | December 15, 2020 | Download |
|
FDA MedWatch Form 3500 24 downloads |
BCBSAL | December 15, 2020 | Download |
|
General-PA Form 3619 downloads |
BCBSAL | December 4, 2020 | Download |
|
Opioid PA-Request Form 362 downloads |
BCBSAL | December 4, 2020 | Download |
|
Part D Form 126 downloads |
BCBSAL | December 4, 2020 | Download |
|
Pegasys 23 downloads |
BCBSAL | December 4, 2020 | Download |
|
Specialty Pharmacy Form 1229 downloads |
BCBSAL | December 4, 2020 | Download |
|
Suboxone Subutex Prior Authorization Request Form 101 downloads |
BCBSAL | December 4, 2020 | Download |
|
Substance Abuse Authorization Form 20 downloads |
BCBSAL | December 4, 2020 | Download |
|
Synagis Authorization Request Form 24 downloads |
BCBSAL | December 4, 2020 | Download |
|
TNF Biologic PA Form 347 downloads |
BCBSAL | December 4, 2020 | Download |